GW1-2023-00904_Well Construction - GW1_20230120

WELL COA'STRUCTION R1' ORD(GN 11 For Internal Ilse Only:
i.Well Contractor Inrrmatlon:
Landon Phillips 14.WATER ZONES
hell CMtmcior Name I FROM 1 TO 1 DESCRUTION
3441A �frj R. dqV n. 3
n. n.
NC Well Contmcmr Certileation Number
IS.OUTER CASING for could-fated well+ OR LINER ifn Iicable
NW Poole Well and Pump Company FRDa+ T DIAA TER TillCKHES$ J+ATF.RIAL
I r t - h l IL aZ 3 ft. L In.• n d r f
Can tan Vame
q 1U.INNER CASING OR TUIIING colhermal chat J•loo
2 Well Construction Permit N:—_J fir//2 ruoM To 1, ..,TER TIIfCKNFSS MATERIAL
Gst n/IopphrnDlr nrl/eomtnrctton ptrnntr p.e.U1C Count Sure,tarlanec,etc.) fL ft. im
3.Well Use(check well usop
Witter Supply Well: 17:SCREEN_
OAgricUlhlml MONT TO DIAMFTER SLOT SIZE TJD KNESS MATEnlAL
;E3R
aVl ublic
❑Gcolllcnnal(Flcating/CoolingSupply) ial Water Supply(single)
❑Indtutrial/Commcrcinl
al Water Supply(shored) IE,GROAT
❑Jeri anon 00 000 OPD Fnoni To a1ATFIl1AL EM1IPLACEA{F{�{M1ICn10D AaIOUNT
Non-\\'ater Supply Well: U ft. 2 rL
ng fl. fL
Injection Well:
❑Aquifer Recharge ❑Groundwater Rcmediation
❑AquifcrStoroge and Recovery ❑SalinityBnrticr 29•SAND/GRAVEL PACK III licahle
F7tOM RlAL
❑AquiFcrTcst ❑StormtvatcrDrainagc n. TO ft. IIIATE EMPt.ACEMENr MEnIOD
❑Experimental Technology ❑Subsidence Control D• ft.
❑Gcolliennal(Closed Loop) ❑Tracer 20.DRILLING LOC n(tach additional sheets if I,etelsa
❑Geothermal(1•Ieating/Cooling Return ❑Other(explain under 1121 Remarks) PRoat TO DFSCRIVIII color hxee—ooittrod tv a in roe era
b_ R. � tr. Tu S •
4.Date Well(s)Completed: /b—�t/-7� Nell 1DN R. / / ft.
Gnr� w ..Aw, •
Sa.Well Location: ) ft. �� ft.
ED
r
f I/ ft. ft.
S�ltr r��„r
Facility/0-11erName Pacility1D11(ifapplieable) ft. ft. 23
�IfIlG�n a ft. f.
Physical Address,City.ahatip rl. fl. Iut•'+
21.REMARKS P.
County Parcel Identification No.(PM) Used hardened steel drive shoe.
5b.Latitude and longitude in degrees/nilnutes/seconds or decimal degrees:
(ifwell field,one lal/lonng is sufficient) 22.Certificnti A;
P ry St taturoofCerlifiedWellConintaor pats -LL
6.Is(nre)Ihcmell(s): ❑I'ermnnent or ❑'Rein ara Mgt � CU•-Z
Ilyslguing ids fosn,I hereby eertrfy that rho wd/N""c'(rerc)eotmrnaed in aceanloice irirh
7.Is this n repair to an existing well: ❑Yes or CINo 15A NCIC 01C.0100 or 13A NCtC 02C.d700 III Calminterlorr Smlulantr and that a wr.
If this is a trpalr,f ll out bioirn it-ell constriction hifornrntlou and explain the namrc of the q tlas record hier been pnirhded to the urB oirncr.
repair tinder 1121 remarks section or on the back of rldsfonn.
23.Site diagram or additional well details:
8.For Geoprobe/DI'T or Closed-Loop Geothermal Wells having die same You may use the back of this page to provide additional vvcll construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of svcils (add'Sco Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:+ 24.SUBMITTAL INSTRUCI'IONS
9.Total well depth below land surface: G/'// SI (fL)
rurauJnple hells fist all depths tfd6rerent(exanip/e.3ta 200'an,12 1007 Submit this CW-1 within 30 drys of well completion per the following:
10.Static water level below lop of casing: 96 (ff) 24a. For All Wells: Original forth to Division of Water Resources(DWR),
If tmirr nerd a abort ca:aiy,are-4^ Information Processing Unit,1617 MSC,Raleigh.NC 27699.1617
11.Borehole diameter: 6 (in.) 24b.For Infection\yells:Copy to DWR,Underground Injection Control(IUCi
Prograin,1636 MSC,Raleigh,NC 27699.1636
0,c Well construction method:etc.)
24c.For Water Supply and O cn-Loo i Geothermal Return Wells:Copy to the
(i,c.attgar,rowy,cable.d'ucct push,crc.) county envuonmentn kcal department of the county vv ere Installed
FOR\VA FER SUPPLY WIiLIS ONLY: 24d.For Water Wells prod 1 over IOU 000 GPD•Copy W U1\'R,CCk'CUA
13a.Yield(Y,Ptn) Method of test:
BLOW Pernit Program,1611 MSC,Raleigh,NC 27699.1611
13b.Bislnfectiwt type: HTH Amuwd; Ib•
Ftnw G W 1 North Catch-Depeiunont of Cuvint—cntal Qunlily-Division of Watcr ltcsotuces Irovise.16�1U 1 E
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